EMB Literature Review Alison Briggs

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Manual versus mechanically-assisted manipulations for acute/subacute low back pain

Low back pain continues to be a prevalent problem in today’s society and is treated in a

variety of ways. One approach is that of spinal manipulation. While manual thrust techniques

are common, mechanically-assisted spinal manipulations are another option that may be used

with similar the similar goal of reducing patients’ level of low back pain. Because I had never

heard of the use of mechanically-assisted manipulation prior to browsing research on spinal

manipulations to treat low back pain, I wanted to investigate whether or not manual or

mechanical manipulations might be considered more useful than the other in patient care.

Going forward, it will be important to know what differences in outcomes, if any, there are

between these two approaches to spinal manipulation with regard to acute or subacute low

back pain.

In a study published in 2015, Schneider et al. conducted a randomized controlled trial

comparing both techniques as well as “usual medical care” for patients experiencing low back

pain. Usual medical care (UMC) as described in this study comprised of the prescription of over

the counter analgesics and anti-inflammatory drugs and recommendation for participants to

remain active and avoid prolonged bedrest. Both spinal manipulation techniques were applied

to a specific segment found via palpation by a licensed chiropractor. In the manual-thrust

manipulation (MTM) group, patients received an HVLA thrust while in side-lying. Mechanical-

assisted manipulation (MAM) was done with participants in prone using the Activator IV
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Instrument. All spinal manipulation techniques were performed by the same chiropractor. UMC

was provided by a physician board certified in physical medicine and rehabilitation.

The article, titled “Comparison of Spinal Manipulation Methods and Usual Medical Care

for Acute and Subacute Low Back Pain,” used a sample of 107 adults who had experienced a

new onset of low back pain (LBP) within the previous 3 months who rated their pain as at least

a 3/10 and disability of at least a 20/100 on the Oswestry LBP Disability Index. Participants had

to also be considered to be good candidates for spinal manipulation and had not received any

treatment for their current episode of LBP other than that provided during the study. Baseline

measures were taken for patient pain and perceived level of disability using a numerical pain

rating scale and the Oswestry LBP Disability Index, respectively. Participants were divided into

the 3 different treatment groups and were seen for 4 weeks. Those in the manipulation groups

were seen twice per week during this time. Those in the UMC group were seen only 3 times

over the course of 4 weeks. All participants were given an educational booklet on LBP.

Results were analyzed in a longitudinal fashion, with participants reporting pain and

disability scores before treatment (baseline), immediately following the 4 weeks of treatment,

and 3 and 6 months after the initiation of treatment. Overall, this study found that participants

who received MTM had significantly better short-term outcomes in both categories than those

who received MAM and UMC. In the short term, MAN and UMC demonstrated similar

outcomes for reported pain and perceived disability. Although all 3 groups demonstrated

improvement in both categories, long term results were once again better in the MTM group,

though there was a more significant difference in pain rating scores than in Oswestry disability
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scores. Interestingly, participants in the MAM showed the highest level of reported pain of the

3 treatment groups at the end of 6 months following an initial decrease at 4 weeks. This

demonstrates a potential lack of lasting effects with regard to pain when using MAM to treat

acute or subacute LBP that was not seen in the other treatment groups. Still, all 3 treatment

groups reported lower levels of pain at 6 months than they had at baseline. Long term results

for perceived level of disability 6 months after initiation of treatment were similar in all groups,

though the MTM group still scored the lowest. Interestingly, the MTM group also showed the

greatest increase in reported disability in the months following treatment, while those in the

other groups continued to have decreasing feelings of disability over time. So, while patient

reported level of disability was of a similar numerical value and was lower in all groups at 6

months than it was at baseline, it is possible that MTM may not offer as effective long-term low

levels of disability as hoped from the initial decrease immediately following treatment.

As discussed in the article, spinal manipulation can be an effective treatment for

subacute or acute low back pain and should be offered to patients as an option for treatment as

long as he or she is an appropriate candidate. Patients and practitioners alike should be aware

that MTM and MAM, while both spinal manipulation techniques, may not offer an equal level

of therapeutic affect as previously assumed.

As a randomized controlled trial, this study offers quality evidence within the specified

participant population. Findings were significant and informative. The results were able to

answer the question of whether or not manual or mechanically-assisted thrust techniques were

more effective, at least in the short term, in decreasing pain and disability in people with acute
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or subacute LBP. That being said, there are some limitations. As with many studies looking at

patient’s with LBP, it is difficult to determine which improvements are due to spontaneous

recovery and which occur as a result of specific interventions. Selection of participants was also

rather specific in that the criteria included the presence of characteristics, such as a recent

onset of localized LBP, which were chosen due to previous research that persons with such

symptoms were likely to experience benefits from spinal manipulation treatment. This makes

results more difficult to generalize to a broader population of patients with LBP, however the

information found in this study can still be useful in guiding clinical practice, particularly when

healthcare providers follow clinical predictive rules with regard to spinal manipulations.

Results from this study will hopefully encourage clinicians considering mechanical-

assisted spinal manipulation using the Activator IV Instrument to talk to their patients about

their preferences as well as risks, benefits, and outcomes of treatment while also challenging

themselves to consider the effects when compared to manual thrust manipulation techniques.

This is an interesting area of study that would benefit from further research, especially as more

and more forms of assistive technology are being used and created even in the realm of manual

therapy. As a future clinician, I will keep this study in mind as I navigate new techniques. I think

it is as important to be aware of as many treatment options as possible as it is to be able to use

clinical reasoning, evidence, and experience to guide in choosing which interventions will offer

the most benefit to each patient as an individual.

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References

1. Schneider M, Haas M, Glick R, Stevans J, Landsittel D. Comparison of Spinal

Manipulation Methods and Usual Medical Care for Acute and Subacute Low Back

Pain. Spine. 2015;40(4):209-217. doi:10.1097/brs.0000000000000724.